Nasal septal perforation in children: Presentation, etiology, and management
Introduction
Nasal septal perforation is an anatomic defect that connects the two nasal cavities through the nasal septum. This anomalous channel results in turbulent airflow patterns and damage to respiratory epithelia, especially when the lesion is large or located in the anterior septum [1], [2], [3], [4]. The presentation, etiology, and treatment of nasal septal perforation have been well described in the adult literature. Common symptoms include dryness, whistling, discomfort, rhinorrhea, crusting, bleeding, and nasal obstruction; however, healed, well-circumscribed perforations in the posterior septum are often asymptomatic [1], [5], [6], [7]. Septal perforations that remain untreated for long periods of time may lead to destruction of respiratory epithelia with loss of cilia, causing the mucosa to become very dry and uncomfortable [7].
Etiology plays an important role in the size, severity, and management of septal perforations. Common causes of adult nasal septal perforation include trauma, intranasal drug use or abuse, infection, neoplasia, connective tissue disorders, and autoimmune disorders, such as granulomatosis with polyangiitis (formerly known as Wegener's Granulomatosis) [1], [4]. It has been suggested that there is a relationship between etiology and the location of the lesion, with systemic disease more likely to result in a posterior perforation than anterior [1]. Ruling out significant underlying conditions is an important step in the diagnostic work-up, as septal perforation may be the initial presentation of some neoplastic processes such as nasal NK/T-cell lymphoma.
While symptoms, etiologies, and treatment options for septal perforation are well described in the adult literature, reports in the pediatric population are limited to case reports and small case series. The purpose of this study is to review our cohort of pediatric nasal septal perforation patients to determine the most common presentation, etiology, and outcomes of these patients. Following a review of our experience, we aim to highlight some of the differences between pediatric and adult perforations.
Section snippets
Methods
The Boston Children's Hospital Institutional Review Board approved this retrospective study prior to acquisition of data, and its guidelines were followed. All pediatric patients under the age of 18 years who were diagnosed with a nasal septal perforation at our institution from 1998 to 2015 were included in this study. Patients who were over the age of 18 years at the time of diagnosis were excluded. We reviewed patient presentation symptoms, etiology, size and location of the perforation, and
Results
A total of 27 patients met inclusion criteria. Patient demographics, presentation, and perforation characteristics are summarized in Table 1. There was no significant gender difference in our series of patients, as 15 (56%) of the patients were male and 12 (44%) were female. The mean age was 10.8 years with a range of 2 months–17 years. Nasal crusting (n = 19, 73%) and epistaxis (n = 15, 58%) were the most common presenting symptoms.
Septal perforations in our series of children occurred most
Discussion
Septal perforations in the pediatric population are rare. Reports in the literature focusing on children with septal perforation are sparse, outside of case reports and small case series of 3 or fewer patients. To our knowledge, this study is the first to evaluate pediatric nasal septal perforation using a relatively large cohort of patients. In our series, children with perforations most commonly presented with nasal crusting (73%). This is primarily the result of dry nasal mucosa secondary to
Conclusions
In our series, septal perforations in children occurred most frequently due to digital nasal trauma, which is different from the adult literature where idiopathic, medication, and traumatic sources are most common. Neoplastic or autoimmune causes were infrequent, but should be considered in pediatric patients with no other clear etiology for their septal perforation. Careful consideration should be given to the etiology of the perforation and cooperativeness of the patient prior to considering
Financial disclosures
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Conflict of interest
None.
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